cms_WV: 11385
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11385 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 514 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, the facility failed to maintain clinical records for one (1) of five (5) residents (#28) in accordance with accepted professional standards and practices that are completed, accurately documented, readily accessible, and systematically organized. The facility failed to obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. readings for analysis, tracking, and trending of abnormal findings. The facility also failed to record on the medication administration record (MAR) each time Tylenol was given from an elevated temperature and failed to record on the reverse side of the MAR whether the medication was effective in reducing his temperature. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his minimum data set assessment (MDS 3.0), an abbreviated quarterly assessment with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10. Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as "High of 99.0 exceeded". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- 3. Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - "Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor." - 10/14/10 at 1:47 p.m. - "Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted." - 10/17/10 at 11:30 a.m. - "REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted." - 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor." - 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor." - 11/05/10 at 10:53 p.m. - "Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor." ?- 11/06/10 at 9:54 p.m. - "Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted." - 11/07/10 at 2:12 a.m. - "Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor." - 11/07/10 at 9:21 p.m. - "Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted." - 11/09/10 at 3:36 a.m. - "S/P (status [REDACTED]." - 11/11/10 at 6:00 a.m. - "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245." - 11/11/10 at 4:36 p.m. - "97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress." - 11/14/10 at 12:01 p.m. - "VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor." - 11/15/10 at 2:42 p.m. - "Residents (sic) mothers (sic) was in today to visit ..." - 11/16/10 at 6:57 a.m. - "resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time." - 11/16/10 at 2:11 p.m. - "Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now." - 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted." - 11/17/10 at 6:01 p.m. - "Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT." - 11/17/10 at 8:28 p.m. - "Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor." - 11/17/10 at 9:48 p.m. - "(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..." -- 4. Review of the resident's November 2010 MAR revealed staff initialed having administered "Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- 5. Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (a) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245.") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - " ... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..." (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - " ... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..." - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). ..." - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature - (b) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." - (c) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. - (d) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. | 2014-04-01 |